6/30 Pumbaa - yo-yo day! All input welcome!!!!!

[Pumbaa]

First, here is a link to Friday's thread/condo, where I explain why I reduced his dose.

Yesterday, after a week of high and flat numbers, Pumbaa finally came through with some blues late last night. He's had this pattern for over three weeks now...a Friday night of low numbers, followed by a bounce, followed by high flat numbers, followed by a dive on Friday night again. Very, very strange.

It was this pattern that Sheila (of Beau & Jeddie fame) noticed and commented that it could be that Pumbaa is getting too much insulin, instead of too little. This boils down to the chronic rebound/Somogyi Rebound effect.

At the same time, if you look at Pumbaa's SS, he was getting a lot more consistent low numbers when his dose was 2.25U (5/30/12 - 6/9/12). On 6/9/12, consistent with the "start low and go slow" protocol, I reduced him to 2.0U as his nadirs had been under 100.

If the lowest point of the curve is below 90 mg/dl (5.0 mmol/L), decrease the dose by 0.5 unit.

When Pumbaa took a dive on Friday night 6/15, and I gave a BCS of 1.5U, but he still dropped to 38 at +2, I then decreased his dose (per the TR protocol) just to a fat 1.75U. I only waited 9 cycles before increasing him back up to 2.0U, he took a dive on Friday 6/22, and everything fell apart after that. He went high and didn't come down for a week, until last night...Friday night's dive once again.

Here's what I am now seeing in hindsight:

• On 6/14, I should NOT have increased him to a fat 2.0U because he had not cleared his bounce after his 6/13 lows. But, he had had 10 cycles at 2.0U, and the lowest point of his curves was below 90. I should have just let him ride at the 2.0U.

• On 6/16, I should NOT have decreased him to a fat 1.75U just because he dropped below 50 the night before. Mixing "start low and go slow" and TR protocols don't seem to work in Pumbaa's case!

So, I would LOVE some more input on Pumbaa's SS, with the understanding that it appears that he dives and bounces, and takes longer than 6 cycles to settle into a dose. From what I can see, Pumbaa is not overly carb sensitive, and I now have most of the %KCal protein/fat/carbs listed on his SS in the right Foods column.

I just need help figuring out my little guy, and get him to more regular, healthier lower numbers. Part of me agrees with the pattern of Somogyi rebound, but part of me thinks that he needed to go back up to 2.25U and stay there for a while until he really settled in.

Thanking everyone in advance for input. And trust me, I have no problem if you point out my dosing mistakes in the past so I can learn for the future. Pumbaa is very important to me, and I am not doing all of this for any reason other than to regulate Pumbaa, and give him a shot at remission.

Suze

 

[Dale 'n' Chip]

Suze I had another thought I don't believe has been addressed elsewhere.

You are lucky with Pumbaa to have the "before insulin" baseline. Toss the vet value and look at your glucose tests before the first shot.

Low pink to high yellow is all the higher he went on the low carb food without insulin. So anything higher than low pink (on the same diet) should be rebound/bounce.

He came out of the gate bouncing after the first U, then hit a blue after shot #2. Then even more bouncing.


Just noticed now you tested ketones "low" before the first shot. After the second or third shot of 1U (and pink to red values) ketones were negative. Later after some more bouncing to red you recorded a trace. I think you said you had concerns those ketone tests might be false positives... but they have been negative ever since? You might move the 15 over to the ketone column, if there is any chance he actually had low ketones.

Did the vet ever test for ketones?

 

[Pumbaa]

Vet had tested for ketones, and some were showing up but I don't know what the level was. After that last "trace" on 4/16/12, he's been negative ever since. It was my understanding that the ketones appeared in the very beginning because, no matter how much I was feeding him, he wasn't getting any nourishment, and so the body was consuming muscle, etc. No?

I kind of discount the vet's BG number because of how agitated Pumbaa was at the vet that day. He actually bit me hard enough to draw blood, require a doctor visit and tetanus shot for me, and I had to fill out an animal bite report, and home quarantine Pumbaa for 10 days to make sure he didn't have rabies.

But that is interesting that you went back and looked at his SS from the beginning, and noticed the very early bounces. I still don't know the exact definition of a bounce. Where did you come up with the "anything over a low pink" would be a bounce? I'm interested in this!

 

[Dale 'n' Chip]

Since you actually tested him after you switched his food those numbers form a pre-insulin baseline.

He could possibly go higher than that on contraband.

When Chip was first taken off NPH for about 10 weeks, his fructosamine test suggested his average glucose was somewhere around 300. With no bouncing, only a steady upward trend from food, he likely never went above mid pink without insulin during that period. Of course within a month after that, back on NPH again his pancreas was working once I weaned him back off insulin.

Sheila was the first one to clue me in that anything red or black (on low carb food) can most likely only come from a bounce, something she discovered with Beau. And I confirmed that long ago when I was looking at Pumbaa's SS.

Correct about how ketones work but it's surprising the vet would send him home if he was throwing anything over a trace.

 

[Pumbaa]

I just looked up my notes from Pumbaa's diagnostic vet visit on 4/4/12. The vet said that Pumbaa tested at 4 for ketones and that I should check him once a week. That "small/15" could have been a mis-read on my part since it was the first time I had tested him. Maybe I read the strip later than 15 seconds. Or maybe he had actually gone up to "small/15" due to the fact that, although he had been on low-carbs for a week, he still wasn't absorbing the food without the insulin? I'm just happy that he consistently tests negative now.

That is interesting about the pre-insulin BG numbers and how to identify bounces. I know that I questioned very early on how Pumbaa could have higher BG number on insulin than he did before he started on the insulin.

Looking back through previous Pumbaa condo's, Mel brought up Somogyi in relation to Pumbaa's numbers way back in April. This was a very interesting discussion that ensued: http://felinediabetes.com/FDMB/viewtopic.php?f=32&t=71133&p=773794#p772484 .

I'm also going back and reading about glucose toxicity. I feel like I've forgotten a lot of what I have read previously.

 

[Dale 'n' Chip]

...Looking back through previous Pumbaa condo's, Mel brought up Somogyi in relation to Pumbaa's numbers way back in April. This was a very interesting discussion that ensued: http://felinediabetes.com/FDMB/viewtopic.php?f=32&t=71133&p=773794#p772484 .

I'm also going back and reading about glucose toxicity. I feel like I've forgotten a lot of what I have read previously.

That is interesting, and you asked Gayle the same question I would ask. I don't see that the pet wikia entry makes distinction between somogyi and liver rebound. If both do the same thing it doesn't matter much. Anyone who's shot and tested a cat has likely seen what happens when they go too low, or just what their body thinks is too low. What we do about it is still the debate.